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ICD-10 Guide
ICD-10 CodesD44.5

D44.5

Billable

Neoplasm of uncertain behavior of pineal gland

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 D44.5 is a billable code used to indicate a diagnosis of neoplasm of uncertain behavior of pineal gland.

Key Diagnostic Point:

Neoplasms of uncertain behavior of the pineal gland represent a category of tumors that do not exhibit definitive malignant or benign characteristics. These tumors can arise from various cell types within the pineal gland, including germ cells, glial cells, and other neuroectodermal tissues. The clinical presentation may vary widely, with symptoms often related to increased intracranial pressure, such as headaches, visual disturbances, and hormonal imbalances due to disruption of the gland's endocrine function. Diagnosis typically involves imaging studies like MRI or CT scans, and histopathological examination is crucial for determining the nature of the neoplasm. Surveillance is essential, as these tumors can exhibit unpredictable behavior, with potential for progression to malignancy. Regular follow-up with imaging and clinical assessment is recommended to monitor for changes in size or symptoms, which may indicate a need for intervention. The management of these neoplasms often requires a multidisciplinary approach, including neurosurgery, oncology, and endocrinology, to address the complexities associated with their uncertain behavior.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and symptoms
  • Need for histopathological confirmation
  • Potential for progression to malignancy
  • Multidisciplinary management requirements

Audit Risk Factors

  • Inadequate documentation of clinical findings
  • Failure to provide imaging results
  • Lack of histopathological reports
  • Insufficient follow-up documentation

Specialty Focus

Medical Specialties

Neurosurgery

Documentation Requirements

Detailed operative reports, imaging studies, and pathology results.

Common Clinical Scenarios

Surgical intervention for tumor resection, management of complications.

Billing Considerations

Clear documentation of tumor characteristics and surgical findings is crucial for accurate coding.

Oncology

Documentation Requirements

Comprehensive treatment plans, follow-up notes, and imaging studies.

Common Clinical Scenarios

Chemotherapy or radiation therapy for tumor management.

Billing Considerations

Documentation must reflect the tumor's behavior and response to treatment.

Coding Guidelines

Inclusion Criteria

Use D44.5 When
  • According to the official coding guidelines, D44
  • 5 should be used when the neoplasm's behavior is uncertain and cannot be classified as benign or malignant
  • Documentation must support the diagnosis, including imaging and pathology reports

Exclusion Criteria

Do NOT use D44.5 When
  • Exclusion criteria include definitive diagnoses of benign or malignant tumors

Related ICD-10 Codes

Related CPT Codes

61500CPT Code

Craniotomy, excision of pineal tumor

Clinical Scenario

Used when a patient undergoes surgical resection of a pineal gland neoplasm.

Documentation Requirements

Operative report detailing the procedure and findings.

Specialty Considerations

Neurosurgery documentation must include tumor characteristics and any complications.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. D44.5 provides a distinct code for tumors of the pineal gland, facilitating better tracking and management of these conditions.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of neoplasms, including those of uncertain behavior. D44.5 provides a distinct code for tumors of the pineal gland, facilitating better tracking and management of these conditions.

Reimbursement & Billing Impact

reimbursement and compliance.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the significance of coding D44.5?

Coding D44.5 is significant as it indicates a neoplasm of uncertain behavior, which requires careful monitoring and management due to its potential for progression. Accurate coding ensures appropriate treatment and follow-up.